Scripps Whittier Diabetes Institute Guide to Patient Management and Prevention

G u i d e t o P at i e n t

Management & Pre vention of Diabetes

At h e n a P h i l i s - T s i m i k a s , M D Corporate Vice President Scripps Whittier Diabetes Institute La Jolla, California

Stephanie Decker, RN, CDE Manager of Professional Education Scripps Whittier Diabetes Institute La Jolla, California

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Contents About the Authors Introduction

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1 Epidemic of Diabetes

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The Global Perspective The Epidemic in the United States What Can You Do? References

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2 Classifications of Glucose Disorders

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Categories of Increased Risk for Diabetes: Pre-Diabetes, Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT) Metabolic Syndrome Polycystic Ovarian Syndrome Type 2 Diabetes Children with Type 2 Diabetes Gestational Diabetes Type 1 Diabetes Diabetic Ketoacidosis Other Causes of Glucose Disorders Web Resources Diabetes Resource Toolkit 2–1 Facts About Diabetes 2–2 Glucose Metabolism 2–3 Types of Diabetes—Scripps Whittier Project Dulce 2–4 Types of Diabetes 2–5 Symptoms of Diabetes 2–6 Blood Glucose Balance 2–7 Blood Glucose Levels 2–8 Estimated Average Glucose or Hemoglobin A1c (A1c)

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Contents

2–9 Blood Sugar Levels and Target Numbers 2–10 Taking Care of Yourself After Having Gestational Diabetes 2–11 Healthy Eating Guidelines After Gestational Diabetes 2–12 Standards of Care 2–13 Diabetes Flow Sheet References

3 Medications Primary Objective Oral Agents Biguanide Sulfonylureas Thiazolidinediones DPP-4 Inhibitors Alpha Glucosidase Inhibitors Meglitinides, Secretagogues Noninsulin Injectable Medications Insulin Basal Insulin Therapy Type 2 Diabetes and Adding Bolus Insulin Mixed-Dose Insulin Type 1 Diabetes Medication Resources for the Patient Diabetes Resource Toolkit 3–1 Injectable Medications (Noninsulin) 3–2 Action Sites of Diabetes Pills 3–3 Diabetes Medicines 3–4 Types of Insulin 3–5 Preparation of Insulin for Injection: Single Dose 3–6 Preparation of Insulin for Injection: Mixed Dose 3–7 Site Selection for Insulin Injection 3–8 How to Give an Insulin Injection

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3–9 Hyperglycemia (High Blood Glucose) 3–10 Hypoglycemia (Low Blood Glucose) 3–11 Correction Bolus Insulin Needed to Lower Your Blood Glucose 3–12 Meal Bolus Insulin Needed to Cover a Meal 3–13 Adjusting Insulin (Basic Principles) References

4 Medical Nutrition Therapy (MNT) and Exercise Calculating Caloric Needs Carbohydrate Counting and Mealtime Insulin Exercise Diabetes Resource Toolkit 4–1 Heart-Healthy Eating Guidelines 4–2 Estimating Portion Sizes 4–3 Weight Loss Tips 4–4 What Are the Sources of Carbohydrates in the Diet? 4–5 Sample Menu 1: 1,500–1,600 Calories 4–6 Sample Menu 2: 1,500–1,600 Calories 4–7 Sample Menu 1: 1,800–2,000 Calories 4–8 Sample Menu 2: 1,800–2,000 Calories 4–9 Make Your Plate Look Like This! 4–10 Make Your Plate Look Like This for Weight Control! 4–11 Food Groups and Serving Sizes 4–12 Dietary Fiber Content of Selected Food 4–13 Fat Facts 4–14 Alcohol and Diabetes 4–15 Your Body Mass Index (BMI) 4–16 The Dos and Don’ts of Exercise 4–17 The Benefits of Exercise 4–18 Chair Exercises References

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5 Diabetes and Heart Disease Walk Hand in Hand: Goals for Glucose, Hypertension, and Dyslipidemia Diabetes Resource Toolkit 5–1 Eat Less Salt 5–2 Sources of Cholesterol and Fat 5–3 Types of Fat in Blood 5–4 Classification of Hyperlipidemia 5–5 Lifestyle Modifications 5–6 HTN Management Program References

6 Standards of Care and Prevention and Treatment of Microvascular and Macrovascular Complications ADA Standards of Care Metabolic Goals to Reduce Complications Diabetes Resource Toolkit 6–1 Diabetes Can Affect All These Parts of Your Body 6–2 Foot Care for People with Diabetes 6–3 Diabetes and Sleep 6–4 Diabetic Ketoacidosis (DKA) 6–5 My Health Goals References

7 Blood Glucose Monitoring Which Meter? Rationale for Home Blood Glucose Monitoring Blood Glucose Recommendations Blood Glucose Goals for Children and Young Adults Alternate Site Testing Physician Role in Home Glucose Monitoring Insulin Pumps: Continuous Subcutaneous Insulin Infusion

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Continuous Glucose Monitoring Diabetes Resource Toolkit 7–1 How Often Should I Test My Blood Glucose? 7–2 Suggested Goals for Blood Glucose References

8 Diabetes and Cultural Considerations Project Dulce’s Program Design Examples of Cultural Considerations in Diets Diabetes Resource Toolkit English 8–1 ABCs of Diabetes Management 8–2 Blood Sugar Levels and Target Numbers 8–3 Foot Care for People with Diabetes 8–4 Treatments Used in Diabetes Spanish 8–5 ABCs of Diabetes Management 8–6 Blood Sugar Levels and Target Numbers 8–7 How to Read a Food Label 8–8 Treatments Used in Diabetes Chinese 8–9 ABCs of Diabetes Management 8–10 Blood Sugar Levels and Target Numbers 8–11 How to Read a Food Label Vietnamese 8–12 ABCs of Diabetes Management 8–13 Blood Sugar Levels and Target Numbers 8–14 How to Read a Food Label References

9 Psychosocial Care Related to Diabetes A Chronic Disease The Office Visit: The Compliance Model versus the Empowerment Model

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Factors in Behavior Change Depression Diabetes Resource Toolkit 9–1 Depression and Diabetes 9–2 Diabetes: Your Emotional Response 9–3 Stress References Index

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About the Authors Athena Philis-Tsimikas, MD Dr. Tsimikas received her medical degree from the University of Athens Medical School, Athens, Greece in 1988. She is certified by the American Board of Internal Medicine in the subspecialty of Diabetes and Endocrinology. She served as a clinical endocrinologist on the staff of the Scripps Clinic Medical Group for 7 years from 1994 to 2001. She assisted in establishing the community-wide, nationally recognized diabetes program, Project Dulce, in 1997 and subsequently joined The Whittier Institute full-time in 2001. She was named Executive Director for the Scripps Whittier Diabetes Institute in 2004 and Corporate Vice President in May of 2008. Stephanie Decker, RN, CDE Ms. Decker is the Manager of Professional Education and Training at the Scripps Whittier Diabetes Institute, La Jolla, California. An RN, CDE for 15 years, she enjoys creating and implementing diabetes training programs for healthcare professionals throughout the United States. Her other experiences include working with low income and culturally diverse community clinics, as well as diabetes care and management in the hospital setting. She is a member of the American Association of Diabetes Educators, is the past President of the San Diego Association of Diabetes Educators, and is a board member of the Behavioral Diabetes Institute.

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Introduction The attention on diabetes has shifted dramatically in the last 20 years. The prevalence rates of the disease have skyrocketed worldwide while the lines between the classic diagnoses of type 1 and type 2 diabetes have blurred with a rising number of children being diagnosed with “adult-onset diabetes.” A plethora of innovative therapies has been introduced into the market, yet our best ammunition in the struggle against diabetes remains clear: practical, evidence-based education for clinicians and patients. Education is critical for modifying lifestyles, including behavioral approaches to preventing and controlling the disease. Training teams of physicians and nurses on how to initiate appropriate medical regimens is also important, and providing tools and approaches for preventing comorbid conditions of diabetes that lead to premature death should be a standard for ensuring best quality care. The rates of developing diabetes continue to rise and are predicted to hit 366 million people worldwide by the year 2030. This guide offers resources that have been developed, tested, and implemented successfully in a variety of real-world, healthcare settings, including diverse, ethnic communities throughout the nation, and can be used in a productive way all over the world. Over the last 15 years, our goal at Scripps Whittier Diabetes Institute has been to develop teams of experts that work in partnership with our physicians, patients, and communities to deliver the best possible approaches to care and prevention of diabetes. Our research has demonstrated improved health, behavioral, and financial outcomes. We trust that you will find these resources useful in building your successful programs. Athena Philis-Tsimikas, MD Corporate Vice President Scripps Whittier Diabetes Institute

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Epidemic of Diabetes

The Global Perspective Every 10 seconds, two people in the world will develop diabetes.1 It is currently estimated that 250 million people worldwide are living with diabetes. By 2025, this number is expected to increase to more than 380 million people.2 The regions with the highest rates are in the eastern Mediterranean and Middle East, where 9.2% of the adult population has diabetes. North America currently has a rate of 8.4%.3 Table 1.1 shows the current and future predicted rates of diabetes in various countries.

Global Costs of Diabetes In poor countries, type 1 diabetes in particular is costly in terms of mortality.4 Many children die because of an inability to obtain insulin. Premature death is a certainty for people with diabetes in many developing countries because of lack of funding and access to medical care. For example, a person in Mozambique who requires insulin will be dead in 12 months. Diabetes affects all people in society, not just those who live with diabetes. The World Health Organization estimates the cost of treating stroke, heart disease, and mortality, as well as the loss of income due to disability in 2005 was approximately $250 billion in China, $225 billion in the Russian Federation, and $210 billion in India. If nothing is done soon to address the global epidemic and management of diabetes, government budgets will face an enormous financial strain related to persons with disabilities, decreased productivity, increased medical expenses, and lost revenue.

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Chapter 1: Epidemic of Diabetes

Table 1.1

Current and Future Diabetes Predictions

2007 People With Diabetes Ages 20–79 Years (millions)

2025 People With Diabetes Ages 20–79 Years (millions)

India

40.9

India

69.9

China

39.8

China

59.3

United States

19.2

United States

25.4

Russian Federation

9.6

Brazil

17.6

Germany

7.4

Pakistan

11.5

Japan

7.0

Mexico

10.8

Pakistan

6.9

Russian Federation

10.3

Brazil

6.9

Germany

8.1

Mexico

6.1

Egypt

7.6

Egypt

4.4

Bangladesh

7.4

2007 Prevalence With Diabetes Ages 20–79 Years (%)

2025 Prevalence With Diabetes Ages 20–79 Years (%)

Nauru

30.7

Nauru

30.7

United Arab Emirates

19.5

United Arab Emirates

19.5

Saudi Arabia

16.7

Saudi Arabia

16.7

Bahrain

15.2

Bahrain

15.2

Kuwait

14.4

Kuwait

14.4

Oman

13.1

Oman

13.1

Tonga

12.9

Tonga

12.9

Mauritius

11.1

Mauritius

11.1

Egypt

11.0

Egypt

11.0

Mexico

10.6

Mexico

10.6

Source: International Diabetes Federation. Contents: data tables. In: IDF Diabetes Atlas. 4th ed. Available at: http://www.eatlas.idf.org/. Accessed October 20, 2009.

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The Epidemic in the United States

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The Epidemic in the United States The following figures illustrate the diabetes epidemic in the United States5: Pre-diabetes: 57 million people Undiagnosed: 5.7 million people Diagnosed: 17.9 million people Total: 23.6 million children and adults The following social and cultural changes contribute to the epidemic of diabetes both in the United States and globally: • Poor lifestyle habits, such as inactivity, obesity, and low-quality food choices, are the primary cause of the epidemic. • Cultural changes include: ❍ Increased television and computer time ❍ Frequent use of convenience and fast foods, dining out ❍ Aging population ❍ Economic growth that provides opportunities to purchase cars, televisions, and computers (items that contribute to sedentary lifestyles) ❍ Job stress and increased work hours

Ethnic Prevalence Age-adjusted prevalence data from the 2004–2006 National Survey are as follows6: • Non-Hispanic whites: 6.6% • Asian Americans: 7.5% • Hispanics: 10.4% ❍ Cubans: 8.2% ❍ Mexican Americans: 11.9% ❍ Puerto Ricans: 12.6% • Non-Hispanic blacks: 11.8% • Native Americans Alaska Natives: 6% ❍ ❍ In southern Arizona: 29.3%

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Chapter 1: Epidemic of Diabetes

U.S. Costs of Diabetes The 2007 costs of diabetes are as follows7: • Total cost: $174 billion • Direct medical costs: $116 billion • Indirect costs: $58 billion 15 million sick days ❍ ❍ 120 million reduced-productivity days ❍ Disability (reduced productivity for those not in the labor force ($0.8 billion), unemployment from disease-related disability ($7.9 billion), and lost productive capacity due to early mortality ($26.9 billion).8

Personal Costs of Diabetes in the United States The 2006 National Healthcare Disparities Report finds disparities related to ethnicity, race, and socioeconomic status still pervade in the U.S. healthcare system.9 People living in the United States have some of the same barriers to diabetes self-care as do those in poorer countries, namely, limited access to quality health care, personal financial and health insurance limitations, and cultural beliefs related to seeking medical care. In 2003, 5.2 million people with diabetes had a cardiovascular diagnosis, and 50,000 people with diabetes required ongoing dialysis treatments. In 2007, 873,000 people with diabetes had a primary or secondary diagnosis of lower extremity condition.10 It is easy to see that for the patient, his or her family, and the community the personal and financial costs of diabetes and the complications of diabetes can add to the burden of living with a chronic disease.

What Can You Do? • Educate yourself and stay informed about the current clinical management recommendations: ❍ The American Diabetes Association makes its most current clinical recommendations available every January at http:// professional.diabetes.org/CPR_Search.aspx.

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References

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The American Association of Clinical Endocrinologists is another great diabetes resource at http://www.aace.com. • Actively work with your state government and the federal government to improve diabetes care: ❍ The Agency for Healthcare Research and Quality has developed a resource titled “Diabetes Care Quality Improvement: A Resource Guide for State Action” that you can access at http://www.ahrq.gov/qual/diabqual/diabqguide.htm. ❍ Join the American Diabetes Association Advocacy Center, which works on the local and federal levels. You can sign up to become a diabetes advocate at http://advocacy.diabetes. org/site/PageServer?pagename=AC_homepage. ❍

References 1. Discovery Health. Diabetes: A Global Epidemic Part 1. Available at: http://discoveryhealthcme.discovery.com/beyond/miniPlayer .html?playerId=1312399220. Accessed October 20, 2009. 2. Silink M. Foreword. In: International Diabetes Federation, IDF Diabetes Atlas. 4th ed. Available at: http://www.eatlas.idf.org/newsc269.html. Accessed October 20, 2009. 3. International Diabetes Federation. Contents: data tables. In: IDF Diabetes Atlas. 4th ed. Available at: http://www.eatlas.idf.org/. Accessed October 20, 2009. 4. International Diabetes Federation. Contents: economic impacts of diabetes. In: IDF Diabetes Atlas. 4th ed. Available at: http://www. eatlas.idf.org/. 5. American Diabetes Association. Total prevalence of diabetes and prediabetes. Available at: http://www.diabetes.org/diabetes-statistics/ prevalence.jsp. Accessed October 20, 2009. 6. National Diabetes Information Clearinghouse. National diabetes statistics, 2007: race and ethnic differences in the prevalence of diagnosed diabetes. Available at: http://diabetes.niddk.nih.gov/dm/ pubs/statistics/#race. Accessed October 20, 2009. 7. US Department of Health and Human Services, Centers for Disease Control and Prevention. National Diabetes Fact Sheet 2007. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf. Accessed October 20, 2009.

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8. American Diabetes Association. Economic costs of diabetes in the U. S. in 2007. Diabetes Care. 2008;31:596–615. 9. US Department of Health and Human Services, Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2006. Available at: http://www.ahrq.gov/qual/nhdr06/nhdr06.htm. Accessed October 20, 2009. 10. US Department of Health and Human Services, Centers for Disease Control and Prevention. Number (in millions) of persons with diabetes aged 35 years and older with self-reported cardiovascular disease conditions, United States, 1997–2007. Available at: http:// www.cdc.gov/diabetes/statistics/cvd/fig1.htm. Accessed October 20, 2009.

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Classifications of Glucose Disorders1

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Categories of Increased Risk for Diabetes: Pre-Diabetes, Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT) Screening Fasting plasma glucose (FPG) or 2-hr 75-g oral glucose tolerance test (OGTT). An OGTT may better define the risk of diabetes in patients who have impaired fasting glucose.

Candidates for Screening Any adult with a body mass index (BMI) greater than or equal to 25 kg/m2 and who has risk factors such as the following: • Inactivity • First-degree relative with diabetes • Diagnosis of gestational diabetes or delivered a baby greater than 9 lb • High-risk ethnic group such as African American, Latino, Pacific Islander, Asian American, or Native American • Diagnosis of hypertension or dyslipidemia • Acanthosis nigricans noted on skin (darkening of skin on the neck or underarms, under the breasts, in the groin area) If no risk factors are present, start screening at age 45 and repeat testing every 3 years unless you note risk factors, and then screen earlier.

Diagnosis 2 FPG ≥100 mg/dL and Blood glucose (BG) 600 mg/dL with no diabetic ketoacidosis (DKA) present. • Leading causes: New onset diabetes or an infection (60%). • Other causes: Glucocorticoids, diuretics, pancreatitis, gastrointestinal bleed, or myocardial infarction. • Patient may present with mental status changes or neurological signs and symptoms. • Also seeing a higher rate of known history of diabetes coming in with HHS as a result of poor diabetes management (stopped taking medications typically). • Higher mortality than DKA because no medical help is sought for weeks or months. • Severe dehydration and electrolyte imbalance. • Treat with IV fluids, insulin, and electrolyte replacement. • Treat any underlying cause. • Patient may or may not need insulin at time of discharge. • Resource for HHS: ❍ Kitabchi AE, Kreisberg RA, Murphy MB, Umpierrez GE. Hyperglycemic crisis in adult patients with diabetes. Diabetes Care. 2006;29:2739–2748.

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Children with Type 2 Diabetes

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Older adults: • Older adults have a higher risk of hypoglycemia resulting from renal changes, comorbidities, visual acuity, dexterity and accuracy concerns with blood glucose monitoring, and, for some, memory problems. • For patients with self-care and safety concerns, individualize A1c and glucose goals to decrease the risk of hypoglycemia. Consider an A1c between 7.0 and 7.5 vs. 85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height and any two of the following risk factors: • Family history of type 2 diabetes in first- or second-degree relative • High-risk ethnic group, such as African American, Latino, Pacific Islander, Asian American, or Native American • Acanthosis nigricans • Hypertension • Dyslipidemia • PCOS

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Chapter 2: Classifications of Glucose Disorders

• Maternal history of diabetes or gestational diabetes during the child’s gestation • Small-for-gestational-age birthweight FPG is the recommended screening for children. If FPG is normal, rescreen in 3 years. • Same diagnostic criteria and labs as type 2 adult. If there is any concern that the patient has type 1 vs. type 2 diabetes, then order islet cell autoantibodies (ICA), glutamic acid decarboxylase (GAD), and insulin autoantibodies (IAA) to rule out a diagnosis of type 1 diabetes.

Treatment of Children with Type 2 Diabetes • Lifestyle counseling: Assess parent’s cultural belief system and understanding of healthy eating. Some cultures feel being overweight is a sign of success and happiness. • Medications: Metformin and glimepiride (8 years of age or older) are currently approved by the Food and Drug Administration for use in children.9 Insulin therapy is also an option. • Goal is to have fasting glucose 3.0 mg/dL

Serum Cr ♀ >1.5 to ≤2.5 mg/dL

Serum Cr ♀ >2.5 mg/dL

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Alpha Glucosidase Inhibitors

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not been studied in patients receiving peritoneal dialysis. It is also recommended to decrease the dose of saxagliptin to 2.5 mg if the patient is also taking cytochrome P450 3A4/5 inhibitors (CYP3A4/5 inhibitors) such as ketoconazole, atazanavir, clarithromycin, indinavir, ritonavir, saquinavir, and telithromycin. The sulfonylurea dose may need to be decreased to prevent hypoglycemia.

Patient Education 1. Once daily dosing. 2. May increase risk of hypoglycemia with use of sulfonylurea, so take precautions. 3. Stop medication and notify MD immediately if you experience any allergic reaction. 4. Women planning to get pregnant who are taking orals often need to go on insulin during the pre-conception period. Early planning with OB-GYN and MD is necessary for proper medication and glucose control prior to pregnancy. 5. Carry ID with you that states “I have diabetes” and include MD name and phone number as well as family contact and medications.

Alpha Glucosidase Inhibitors13,14 Use Slow down the absorption of carbohydrates through the small intestine, resulting in a decrease in the postprandial glucose level.

Dosage Patients should take 25 mg with the first bite of breakfast, lunch, and dinner. If patient has GI complaints, he or she may start out with one at the largest meal and increase weekly to TID. Increase dose by 25 mg every 4 to 8 weeks. Check the postprandial glucose to evaluate dose effectiveness. Only use >50 mg TID if patient body weight >60 kg because of the risk of increased serum transaminase.

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Chapter 3: Medications

Possible Side Effects GI complaints, abdominal pain, diarrhea, flatulence.

Precautions and Contraindications Dose-related elevation of alanine transaminase (ALT) and/or aspartate aminotransferase (AST), more common in females, reversible, and not associated with liver dysfunction. Check ALT/AST every 3 months during the first year of treatment. No studies with patients who have a SrCr >2 mg/dL. Contraindicated with pregnancy and lactation, cirrhosis, inflammatory bowel disease, or malabsorption disorders and diabetic ketoacidosis.

Patient Education 1. Take with the first bite of each meal. 2. Risk of hypoglycemia increases with use of sulfonylurea or insulin. 3. If hypoglycemia occurs, need to treat with glucose such as glucose gel or tablets; absorption of fruit juice will be delayed as a result of drug effect. 4. GI side effects will diminish over several weeks. 5. Women planning to get pregnant who are taking orals often need to go on insulin during the pre-conception period. Early planning with OB-GYN and MD is necessary for proper medication and glucose control prior to pregnancy. 6. Carry ID with you that states “I have diabetes” and include MD name and phone number as well as family contact and medications.

Meglitinides, Secretagogues15,16 Use Stimulate the pancreas to release insulin rapidly but have a shorter duration than do the sulfonylureas; therefore, less risk of postmeal hypoglycemia. May be beneficial for patients with erratic eating schedules.

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Meglitinides, Secretagogues

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Dosage When starting repaglinide (Prandin), for patients previously not treated or with A1c 8% and previously treated with diabetes medications. In patients with severe renal impairment, start at 0.5 mg dose (no studies conducted on patients with ESRD). When starting nateglinide (Starlix), dose is 120 mg with each meal. Use nateglinide in 60-mg doses if A1c is near goal.

Possible Side Effects Generally well tolerated with a lower risk of hypoglycemia than with the sulfonylureas.

Precautions and Contraindications Caution with patients who have impaired liver function and renal function. Consider lower doses and increase doses carefully. Prandin is contraindicated in use with NPH insulin. It is also contraindicated with pregnancy and lactation.

Patient Education 1. Take 1 minute to 30 minutes before a meal. 2. Do not take a pill if you skip the meal. 3. Carry a fast sugar source with you at all times in the event of hypoglycemia. 4. Women planning to get pregnant who are taking orals often need to go on insulin during the pre-conception period. Early planning with OB-GYN and MD is necessary for proper medication and glucose control prior to pregnancy. 5. Carry ID with you that states “I have diabetes” and include MD name and phone number as well as family contact and medications.

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Chapter 3: Medications

Noninsulin Injectable Medications Incretin Mimetics Incretins such as GLP-1 and glucose-dependent insulinotropic peptide, also known as GIP, are naturally occurring hormones secreted from the intestine in response to food intake. In the pancreas, incretin hormones act to increase glucose-dependent insulin secretion from beta cells. This action helps to ensure an appropriate insulin response following ingestion of a meal.17

Exenatide (BYETTA)18 A synthetic version of a protein, exendin-4, was first identified in Gila monster saliva (Heloderma suspectum).19 This lizard hormone is about 50% identical to the GLP-1 hormone in humans. Use To be used with patients who have type 2 diabetes only. Exenatide stimulates the beta cells to release insulin, decreases glucagon release therefore decreasing hepatic glucose release, and slows down gastric emptying, which lowers postprandial levels and increases satiety. Approved for use with metformin, sulfonylureas, or a thiazolidinedione. Dosage Start at 5 mcg administered before the morning and evening meals or before the two largest meals of the day (need to be 6 hours apart). Should be administered within 60 minutes of the meal. Do not administer after a meal. After 1 month, increase dose to 10 mcg twice daily based on clinical response. Administer into thigh, abdomen, or upper arm. Possible Side Effects GI—nausea, vomiting, diarrhea, dyspepsia (to diminish these side effects patients should inject closer to actual time of eating). Feeling jittery, dizziness, and headache may occur.

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Precautions and Contraindications Contraindicated with type 1 diabetes, ESRD or renal impairment (Cr clearance 9%. Severe hypoglycemia associated with SYMLIN may occur within the first 3 hours following the injection. No studies have been done in patients on dialysis or with hepatic impairment. Do not mix insulin and SYMLIN together. Patients taking medications requiring rapid absorption should take these medications 1 hour prior or 2 hours after injecting SYMLIN because of the gastric slowing effect of SYMLIN. Patient Education 1. Inject subcutaneously and do not mix with insulin. 2. Reduce mealtime insulin by 50%. 3. Only inject if the meal contains ≥250 k/cal or ≥30 g of carbohydrate. 4. Inject SYMLIN and insulin at least 2 inches apart. 5. Do not take SYMLIN if you skip a meal or your glucose is too low. 6. Do not use SYMLIN if the liquid is cloudy. Return the vial to the pharmacy. 7. Check your glucose before and 2 hours after each meal and at bedtime. 8. Call for insulin adjustments. 9. Pen or vials can be refrigerated or kept at room temperature for 30 days once opened. 10. Keep unopened vials or pens in the refrigerator. 11. Notify MD if planning to conceive. SYMLIN will need to be d/c. Early planning with OB-GYN and MD is necessary for proper medication and glucose control prior to pregnancy. 12. Carry ID with you that states “I have diabetes” and include MD name and phone number as well as family contact and medications.

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Insulin Considerations prior to initiating insulin: • Attitude: ❍ How does the patient feel about starting insulin? What are his or her concerns or fears? ❍ Addressing the patient’s cultural beliefs and preconceived ideas about insulin can increase the likelihood that he or she will follow through with your recommendations. ❍ Does the patient understand the purpose and need for insulin? ❍ Your attitude and the way you approach starting insulin may influence the patient’s willingness to start insulin therapy. • Ability: ❍ Visual acuity ❍ Dexterity ❍ Ability to read, comprehend, literacy ❍ Memory • Possible education needs: ❍ Glucose meter ❍ Basic diabetes care guidelines ❍ Hypoglycemia • Support: ❍ Does the patient have a support person? • Finances: ❍ Which insulin options can the patient afford? There are two main types of insulin: • Basal insulin (background insulin) ❍ Serves to inhibit glycogenolysis and gluconeogenesis. ❍ It has no effect on food. ❍ It is released in a slow, steady manner. • Bolus insulin (nutrition or correction insulin) ❍ Given at mealtimes to process carbohydrates ❍ Used as a correction insulin to bring the blood glucose back to goal.

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Table 3.4 Basal Insulin Options Types of Basal NPH* Novolin Insulin Humulin

Glargine† Lantus

Detemir* Levemir

Onset

2–4 hr

1.6 hr

1–2 hr

Peak

4–12

Minimal

Minimal

Duration

Up to 24 hr

Up to 24 hr

Up to 24 hr

Caution

Potential for Do not mix with Do not mix hypoglycemia at any other insulin with any other peak insulin

Cost‡

$54–$58

$104

$104

*From: Novo Nordisk. Novo Nordisk Insulin and Delivery System Portfolio [brochure]. Bagsværd, Denmark: Novo Nordisk; 2007. † From: Sanofi-Aventis. Dosing and Titration Options for Basal and Prandial Insulin [brochure]. Bridgewater, NJ: Sanofi-Aventis; 2008. ‡ From: Drugstore.com; May 2009. Prices will vary at individual locations and pharmacies.

Basal Insulin Basal insulin provides about 50% 22 of daily insulin requirements and is relatively continuous over 24 hours. Helps control hepatic glucose output between meals and overnight. All of these types of insulin, listed in Table 3.4, can be given once or twice daily.

Basal Insulin Therapy Starting Basal Insulin for Type 2 Diabetes23 1. 2. 3. 4. 5.

A1c is not at goal. Fasting glucose levels are elevated. Patient is willing to take one injection. Patient is willing to check fasting glucose. Patient is on maximum oral agents.

Considerations with Starting Basal Insulin 1. Typical starting basal dose is 0.1 (lower body mass index [BMI] or A1c level) to 0.2 unit (higher BMI or A1c level >9) per kilogram of weight.

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2. Continue with current oral antidiabetic agents24 at same doses, except Avandia, which is contraindicated with insulin.25 3. Usually given at bedtime, which decreases the fasting glucose and allows daytime oral antidiabetic agents to work. 4. NPH has a peak, which means the patient has a higher risk of hypoglycemia and appropriate patient teaching and cautious adjustments should be implemented. 5. It is recommended when starting basal insulin or increasing the dose that the patient check a glucose reading in the middle of the night to assess for risk of hypoglycemia. Here is an example of calculating a starting dose of basal insulin: Weight 202 lbs and A1c 9.6: 202 lbs ÷ 2.2 kg = 92 kg × 0.2 unit of insulin = 18 units of basal insulin

Advancing Basal Insulin at Home There are two options: 1. Patient calls the office weekly for adjustments by MD, nurse practitioner, or physician’s assistant. 2. If the patient is capable, he or she may adjust his or her own insulin dose every 3 days until the fasting goal is reached. Typically, this is an adjustment of 1 or 2 units every 3 days until the fasting glucose level is at goal. Individualize your patient’s fasting goal; for someone who is labile or elderly, a fasting goal of 120–130 mg/dL may be safer than a goal of 100 mg/dL.

Patient Education for Starting Basal Insulin 1. Take insulin at the same time each day. 2. Do not mix any other insulin with glargine or detemir. 3. Basal insulin has no effect on food, so continue to eat healthfully and be active. 4. Carry a fast sugar source with you at all times. 5. Continue to take your diabetes pills as prescribed. 6. Glargine must be discarded in 28 days after opening.26 Detemir must be discarded after 6 weeks, and NPH in 30 days.27

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7. Rotate the injection sites. 8. Carry ID with you that states “I have diabetes” and include MD name and phone number as well as family contact and medications. 9. Call MD as fasting glucose gets close to goal as your diabetes pills may need to be decreased or stopped.

Type 2 Diabetes and Adding Bolus Insulin28 1. 2. 3. 4.

Fasting glucose is in range. Daytime glucose levels are elevated. A1c is not at goal. Patient basal insulin dose >0.5–0.7 u/kg/day.

Considerations for Adding Bolus Insulin 1. There are several methods to initiate bolus insulin: a. Add bolus insulin only to the largest meal of the day by giving 10% of the total daily dose (TDD) as rapid-acting analog and reducing the basal dose by 10%.29 Example: Patient is currently taking 50 units TDD. Ten percent of 50 units = 5 units. Patient will begin 5 units rapid-acting analog at largest meal and decrease basal by 10% = 45 units basal insulin. b. Add bolus insulin to all three meals of the day by taking 0.1 unit/kg and distributing at the meals.30 Example: 90 kg × 0.1 = 9 units ÷ 3 meals = 3 units at each meal. 2. Discontinue sulfonylureas, exenatide (BYETTA), DPP-4 inhibitors24 especially when advancing to multiple daily mealtime bolus injections. 3. Caution: When using NPH insulin as a basal insulin BID, bolus insulin is given at breakfast and dinner only because of the peak of the morning NPH during lunch time. 4. Carbohydrate counting provides mealtime flexibility for the patient who is capable of carrying out this higher level of management. (See Chapter 4, Medical Nutrition Therapy (MNT) and Exercise.) See Table 3.5 for information on bolus insulin options.

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Table 3.5 Bolus Insulins Regular Novolin Humulin*

Glulisine Apidra†

“Short acting” “Rapid acting”

Lispro Humalog*

Aspart Novolog‡

“Rapid acting”

“Rapid acting”

Onset: 30 min Onset: 5–15 min Onset: 5–15 min Onset: 10–20 min Peak: 2–4 hr Peak: 30–90 min Peak: 30–90 min Peak: 40–50 min Duration: Duration: